Wellness Bites!

Quick overview 

• The central government health scheme provides outpatient and inpatient health services.
• It includes the service of employees, pensioners, and their dependents who are entitled to the service.
• Treatment is available to beneficiaries at CGHS wellness centres and under empanelled hospitals.
• There is cashless treatment in selected central government health scheme hospitals.
• Various medical systems are included, such as Allopathy and AYUSH.
• These include medicines, diagnostics, specialist consultation,s and hospitalisation.
• There is a systematic reimbursement system for approved treatments.
• CGHS is a large central government health insurance scheme for employees.

Central Government Health Scheme (CGHS) is a scheme that is among the most comprehensive government-funded schemes in India; it is aimed at offering affordable and reliable medical services to qualified central government employees and pensioners.

Introduction to Central Government Health Scheme

The central government health scheme was initiated to provide the central government employees and pensioners with quality healthcare without the high cost of medical care. It operates as a welfare-based initiative which provides preventive, curative, and promotional health care services via an extensive network of healthcare facilities.

Role of CGHS in the  Government Healthcare System

CGHS is an important part of the Indian healthcare system as it is a well-organised healthcare service provider for government employees. It is an intermediary between state hospitals and the private healthcare system, since it empowers hospitals and sets the prices of the treatment at standardised rates.

Purpose and Objectives of CGHS

The Central Government Health Scheme (CGHS) has a special purpose and objectives that extend beyond the provision of basic medical treatment to the beneficiaries and are aimed at the provision of long-term healthcare security. The scheme will help to provide easy access to quality healthcare services to central government employees, pensioners and their dependents, regardless of their income status or medical needs. CGHS assists in minimising out-of-pocket health care costs by providing subsidised and regulated medical care and healthcare services, particularly for expensive treatments and chronic health conditions.

The other important goal of CGHS is to guarantee prompt and uninterrupted medical treatment using an organised system of CGHS wellness centres, dispensaries, and empanelled hospitals. This entails outpatient visits, referrals to specialists, diagnostic visits and hospitalisation, all of which are synchronised under a single system. The scheme also lays a lot of emphasis on preventative healthcare, whereby it promotes early diagnosis, routine check-ups, and continuous management of chronic illnesses to minimise complications and healthcare expenditure in the long run.

CGHS also aims to establish a standardised and homogenous healthcare system for government workers in various cities by adopting common treatment guidelines and a standardised CGHS rate list. This will provide transparency, contain treatment costs, and avoid overcharging by hospitals. In general, the central government health scheme is an important social security initiative that fosters health equity, financial security, and quality of life among government employees and retirees in India.

History and Evolution of CGHS in India

The Central Government Health Scheme (CGHS) was launched in 1954 to cater to the healthcare needs of central government employees in select urban areas. Initially limited in scope, the scheme gradually expanded to include pensioners, freedom fighters, and their dependents. 

Over time, CGHS evolved by empanelling private hospitals, introducing cashless treatment, standardising treatment rates, and adopting digital systems for appointments, health records, and beneficiary management, making healthcare delivery more efficient and accessible.

Key Features of the Central Government Health Scheme

1. Comprehensive Healthcare Coverage - The scheme provides coverage for outpatient consultations, inpatient hospitalisation, diagnostic tests, surgeries, and post-treatment follow-up care. Both acute illnesses and long-term chronic conditions, such as diabetes, hypertension, and heart disease, are managed under CGHS as per approved medical protocols.
2. Cashless Treatment at CGHS Facilities - Beneficiaries can avail cashless treatment at CGHS wellness centres and empanelled government and private hospitals. Treatment expenses are settled directly between the hospital and CGHS within the approved rate limits, reducing the financial burden during medical emergencies and planned procedures.
3. Reimbursement-Based Medical Services - When treatment is taken at non-empanelled hospitals or in emergency situations, CGHS allows reimbursement of medical expenses. Claims are processed based on CGHS-approved rates, subject to the submission of complete documents within the stipulated time.
4. Wide Network of CGHS Wellness Centres - CGHS operates a large number of wellness centres across covered cities, serving as the primary healthcare point for beneficiaries. These centres provide OPD services, medicines, basic diagnostics, and referrals to specialists.
5. Access to Empanelled Hospitals - The scheme includes an extensive list of empanelled government and private hospitals, allowing beneficiaries to access specialised and advanced medical care across multiple locations.
6. Multiple Systems of Medicine - CGHS covers treatment under Allopathy as well as AYUSH systems such as Ayurveda, Yoga, Unani, Siddha, and Homoeopathy, giving beneficiaries flexibility in choosing their preferred mode of treatment.
7. Standardised CGHS Rate List - A predefined CGHS rate list regulates the cost of treatments, procedures, and diagnostics. This ensures transparency, prevents overcharging, and maintains uniformity in healthcare expenses across hospitals.
8. Specialist Referral and Consultation System - Specialist consultations and advanced treatments are provided through a structured referral system, ensuring appropriate medical care while maintaining cost control and treatment accountability.
9. Preventive Healthcare Focus - CGHS promotes preventive healthcare through regular health check-ups, early diagnosis, and monitoring of chronic conditions, particularly for senior citizens and pensioners.
10. Digital Services and Online Access - The scheme has integrated digital platforms for appointment booking, CGHS card management, grievance redressal, and health record access, improving convenience and service efficiency for beneficiaries.

Benefits of the  Central Government Health Scheme

 

Benefit Area	Explanation
Affordable Healthcare for Government Employees	CGHS significantly reduces healthcare expenses by offering medical services either free of cost or at highly subsidised rates, ensuring quality treatment for serving employees and pensioners without financial strain.
Access to CGHS Dispensaries Across Cities	A central government health scheme dispensary, also called a CGHS wellness centre, acts as the primary healthcare access point, providing OPD consultations, medicines, basic diagnostics, and referrals.
Preventive and Curative Healthcare Benefits	The scheme encourages preventive healthcare through routine check-ups, early diagnosis, and continuous monitoring, while also covering curative treatments such as surgeries and hospitalisation.
Cashless Treatment Facility	Beneficiaries can avail cashless treatment at CGHS wellness centres and empanelled hospitals, reducing the need for upfront payments during medical emergencies or planned procedures.
Coverage for Pensioners and Dependents	CGHS extends healthcare benefits to retired employees and eligible dependents, ensuring long-term medical security even after retirement.
Availability of Specialist Consultations	Access to specialist doctors through a structured referral system ensures timely expert care for complex and chronic medical conditions.
Standardised Treatment Costs	Treatment charges are regulated through CGHS rate lists, protecting beneficiaries from excessive medical billing in private hospitals.
Medicine Supply Through Dispensaries	Prescribed medicines are provided free of cost through CGHS dispensaries, helping reduce recurring medical expenses for chronic conditions.
Emergency Medical Care Support	Emergency treatments taken at non-empanelled hospitals can be reimbursed as per CGHS rules, ensuring beneficiaries are not denied urgent care.
Multi-System Medical Coverage	CGHS supports Allopathy and AYUSH systems, allowing beneficiaries to choose between modern and traditional treatment options.

Eligibility Criteria for Central Government Health Scheme

Eligible Serving Central Government Employees

All serving central government employees working in CGHS-covered cities are eligible, subject to making the prescribed monthly contribution.

Eligibility for Pensioners and Retired Employees

Pensioners of the central government and certain autonomous bodies can enrol by making a one-time contribution or annual payment.

Eligibility of Dependents Under CGHS

Dependent family members such as spouse, children, and dependent parents are covered, provided they meet dependency criteria under CGHS rules.

Components of the Central Government Health Scheme

CGHS Wellness Centres and Dispensaries

These centres provide OPD consultations, basic diagnostic services, medicine distribution, and referrals to specialists or hospitals.

Diagnostic and Laboratory Services

CGHS offers access to approved diagnostic tests either at wellness centres or empanelled diagnostic labs, ensuring accurate and timely investigations.

Specialist Consultation and Referral System

Specialist care is available through referrals from CGHS medical officers, ensuring controlled and standardised access to advanced treatment.

Types of Medical Systems Covered Under CGHS

Allopathy Medical Services

Allopathic treatments form the core of CGHS services, covering general medicine, surgery, diagnostics, and hospitalisation.

AYUSH Treatment Coverage

CGHS also covers AYUSH systems such as Ayurveda, Yoga, Unani, Siddha, and Homoeopathy, offering alternative treatment options.

Preventive Health Check-Up Services

Preventive health services, including regular check-ups for senior citizens, are encouraged under CGHS guidelines.

Central Government Health Scheme Dispensary Services

Role of CGHS Dispensaries

A central government health scheme dispensary functions as the primary healthcare provider, managing OPD care and referrals.

Services Offered at CGHS Wellness Centres

Services include doctor consultations, issuance of medicines, basic diagnostics, and follow-up care for chronic conditions.

Medicine Distribution Through CGHS Dispensaries

Prescribed medicines are provided free of cost through CGHS dispensaries, reducing recurring medical expenses for beneficiaries.

Central Government Health Scheme Hospitals

Government Hospitals Under CGHS

CGHS beneficiaries can receive treatment at government hospitals recognised under the scheme, often without cash payments.

Private Empanelled Hospitals Under CGHS

Numerous private hospitals are empanelled as central government health scheme hospitals, offering specialised treatments as per CGHS rates.

Treatment in Private Hospitals as per the CGHS Rate List

Treatment costs in private hospitals are regulated using the CGHS rate list, ensuring affordability and standardisation.

Facilities Offered Under the Central Government Health Scheme

Facility Type	Details
Outpatient Department (OPD) Services	OPD services include consultations with CGHS medical officers, follow-up visits, treatment for common illnesses, and prescription of medicines for acute and chronic conditions.
Specialist OPD Consultations	Beneficiaries can consult specialists such as cardiologists, orthopaedicians, and physicians through referrals issued by CGHS doctors at wellness centres.
Diagnostic Services	Basic diagnostic tests and investigations are provided at CGHS wellness centres or approved diagnostic laboratories as per CGHS guidelines.
Inpatient and Hospitalisation Facilities	CGHS covers hospitalisation for surgeries, critical care, and specialised treatments at empanelled government and private hospitals, subject to referral and approval.
Day-Care Procedures	Several approved day-care procedures that do not require prolonged hospital stays are covered under the scheme.
Emergency Medical Treatment Coverage	In medical emergencies, beneficiaries can seek treatment at the nearest hospital, including non-empanelled hospitals, with reimbursement allowed as per CGHS norms.
Post-Hospitalisation Follow-Up	Follow-up consultations, medicines, and related care after discharge are covered when linked to approved hospitalisation.
Referral and Approval System	A structured referral mechanism ensures appropriate treatment access while maintaining cost control and treatment accountability.
Medicine Supply During Treatment	Medicines prescribed during OPD or hospitalisation are provided free of cost through CGHS dispensaries or reimbursed when applicable.
Support for Chronic Disease Management	Long-term treatment and monitoring for chronic illnesses such as diabetes and hypertension are managed through regular OPD follow-ups.

Cost and Contribution Under the Central Government Health Scheme

Monthly Contribution for Serving Employees

Serving employees contribute a fixed monthly amount based on their pay level, deducted directly from their salary.

One-Time Contribution for Pensioners

Pensioners can opt for a lifetime CGHS membership by paying a one-time contribution based on their last pay drawn.

CGHS Charges Based on Pay Level

Contribution rates are structured according to pay levels under the 7th Pay Commission.

CGHS Card and Its Importance

What is a CGHS Card?

A CGHS card is an official identification document issued to eligible beneficiaries under the Central Government Health Scheme. It serves as proof of enrollment and authorises the cardholder to access healthcare services provided through CGHS wellness centres, dispensaries, and empanelled hospitals. The card contains essential details such as the beneficiary’s name, category, card number, and information about dependent family members covered under the scheme.

CGHS Card Benefits for Beneficiaries

One of the key benefits of the CGHS card is that it enables cashless medical treatment at CGHS wellness centres and empanelled central government health scheme hospitals, subject to scheme rules and CGHS rate limits. Cardholders can avail OPD consultations, obtain prescribed medicines free of cost, access diagnostic services, and receive specialist referrals. The CGHS card is also required while claiming reimbursement for medical expenses incurred in approved or emergency treatments.

Validity and Usage of CGHS Card

Regarding validity and usage, the CGHS card remains valid as long as the beneficiary continues to meet eligibility criteria and makes the required contributions on time. For serving employees, validity is linked to active service and monthly contributions, while for pensioners, it depends on the payment of annual or lifetime contributions. The card must be presented at the time of availing any CGHS service, and misuse or non-compliance with CGHS rules may lead to suspension or cancellation of benefits.

How to Apply for a CGHS Card

• Eligible beneficiaries can apply for a CGHS card through the official CGHS online portal by selecting the appropriate category, such as serving employee or pensioner.
• Applicants must create a user account using basic details like mobile number, email ID, and employment or pension information.
• The online application form requires personal details, office or pension details, residential address, and CGHS-covered city selection.
• Details of dependent family members, including relationship, age, and dependency status, must be accurately entered.
• Applicants are required to upload scanned copies of necessary documents such as identity proof, address proof, proof of employment or pension, and photographs of beneficiaries.
• Serving employees must select the applicable monthly contribution category, while pensioners must choose between annual or lifetime contribution options.
• After form submission, the application is forwarded for verification by the concerned department or CGHS authorities.
• Once verified, applicants receive an acknowledgement or provisional CGHS card that can be used until the physical or final card is issued.
• The final CGHS card is generally issued within a few weeks, depending on document verification and administrative processing.
• Applicants can track the application status online using their registered credentials until the CGHS card is activated.

CGHS Appointment Booking Process

• Beneficiaries must visit the official CGHS online services portal and log in using their registered CGHS card number, registered mobile number, or user credentials.
• After logging in, users can select the option for booking an appointment at their linked CGHS wellness centre or dispensary.
• The system displays available doctors along with consultation schedules for general OPD services.
• Beneficiaries can choose a preferred doctor, date, and time slot based on availability shown on the portal.
• Once the appointment details are confirmed, an online appointment slip or token number is generated, which should be saved or printed for reference.
• On the appointment date, beneficiaries must visit the wellness centre and present their CGHS card and appointment slip at the registration counter.
• For specialist consultations, beneficiaries must first consult a CGHS medical officer at the wellness centre.
• If specialist care is required, the CGHS doctor issues an official referral specifying the speciality and approved hospital or clinic.
• Specialist appointments can then be booked either online or as directed by the CGHS wellness centre, depending on the speciality and facility.
• Emergency cases do not require prior appointment or referral, and beneficiaries can directly approach the nearest hospital for treatment.

CGHS Rate List Explained

The CGHS Rate List is an officially notified schedule of approved charges for medical procedures, surgeries, diagnostic tests, investigations, and hospital services under the Central Government Health Scheme. It is issued and periodically revised by the government to reflect reasonable and regulated healthcare costs across different cities. The rate list serves as a benchmark for treatment expenses at both government and empanelled private hospitals.

Importance of the CGHS Rate List for beneficiaries:

• It ensures transparency in medical billing and helps beneficiaries clearly understand the maximum permissible cost of treatment.
• The rate list protects beneficiaries from excessive or unjustified charges by private hospitals.
• It allows uniform treatment costs across empanelled hospitals, regardless of location.
• Reimbursement claims are processed strictly based on CGHS-approved rates, ensuring fairness and consistency.
• Beneficiaries can plan treatments knowing the approved cost limits in advance.

CGHS rate applicability in private hospitals:

• All empanelled private hospitals are required to strictly follow the CGHS rate list for consultations, diagnostics, procedures, and hospitalisation.
• Hospitals cannot charge CGHS beneficiaries more than the prescribed rates for approved treatments.
• Any additional charges beyond CGHS rates must be clearly informed and are usually not reimbursable.
• In case of overcharging, beneficiaries can raise grievances with the CGHS authorities for corrective action.

Overall, the CGHS rate list plays a crucial role in controlling healthcare costs, ensuring affordability, and maintaining standardised medical care for all CGHS beneficiaries.

Linking CGHS with ABHA ID

Linking CGHS with ABHA ID is an important step toward integrating the Central Government Health Scheme with India’s national digital health ecosystem. The ABHA (Ayushman Bharat Health Account) ID acts as a unique digital health identity that allows beneficiaries to securely store and access their health records across healthcare providers and platforms.

Importance of linking CGHS to ABHA ID: 

Linking the CGHS card with an ABHA ID enables seamless digital integration of medical records generated through CGHS wellness centres, dispensaries, and empanelled hospitals. It supports continuity of care by allowing doctors to view past prescriptions, diagnostic reports, and treatment history, leading to better clinical decisions. This integration also aligns CGHS services with national digital health initiatives, improving transparency and efficiency.

Steps to link the CGHS card with the ABHA ID:

Beneficiaries can create or access their ABHA ID through official government health portals or authorised platforms. After generating the ABHA ID, CGHS beneficiaries can link their CGHS card by providing the required details such as the CGHS card number, registered mobile number, and personal identification. OTP-based verification ensures secure linking of records. Once linked, health data generated through CGHS services can be automatically associated with the ABHA ID.

Benefits of digital health integration:

Linking CGHS with ABHA ID allows easy access to medical records anytime and anywhere, reducing the need to carry physical documents. It improves coordination between different healthcare providers, speeds up consultations, and enhances the overall quality of care. Digital integration also supports faster claim processing, better health monitoring, and a more patient-centric healthcare experience for CGHS beneficiaries.

Limitations of the Central Government Health Scheme

• Many CGHS centres in large cities face overcrowding, leading to long waiting times for consultations and diagnostics.
• Limited specialist availability and insufficient infrastructure can delay treatment for complex or chronic conditions.
• Beneficiaries often lack awareness of CGHS services, eligibility criteria, and procedures, causing inconvenience.
• Quality of care varies across facilities, with smaller centres sometimes lacking experienced staff or modern equipment.
• Communication gaps and low awareness of online services like appointment booking and ABHA ID linking reduce efficiency.
• Emergency and advanced care may be limited in some centres, requiring reimbursement-based treatment at private hospitals.

Treatments Not Covered Under the Central Government Health Scheme

Exclusion Type	Details
Cosmetic Procedures	Treatments performed purely for aesthetic or cosmetic purposes, such as plastic surgery or beauty-related procedures, are not covered.
Non-Essential Treatments	Procedures or therapies that are not medically necessary or not listed under CGHS-approved treatments are excluded.
Non-Admissible Medical Procedures	Any medical service, diagnostic test, or surgery performed outside CGHS-approved guidelines or packages is not reimbursable.
Treatments Without Referral	Expenses incurred for specialist consultations, hospitalisation, or procedures without a proper referral from a CGHS medical officer may be rejected.
Non-Empanelled Hospitals	Treatment taken at hospitals not empanelled under CGHS, unless in emergencies with prior approval, is generally not eligible for reimbursement.
Over-the-Limit Expenses	Costs exceeding CGHS-approved rates, including additional hospital charges or private room upgrades, are not covered.

Central Government Health Scheme Mediclaim and Reimbursement

• Submission of Claims: Beneficiaries must submit reimbursement claims for treatments not covered under cashless facilities. This includes expenses for non-empanelled hospitals, certain diagnostics, or emergency treatments taken outside the CGHS facility.
• Complete Documentation Required: Each claim must be supported by proper documents, including the hospital bills, prescriptions, diagnostic reports, discharge summaries, CGHS card details, referral letters (if applicable), and any payment receipts. Incomplete submissions can lead to delays or rejection.
• Time Limit for Submission: Claims should generally be submitted within three months from the date of treatment. Delays beyond the prescribed timeline may result in partial or complete denial of reimbursement.
• Verification by CGHS Authorities: Once the claim is submitted, CGHS authorities verify all details, including hospital authenticity, treatment validity, referral approval, and whether the charges fall under CGHS-approved rates.
• Processing and Approval: After verification, the approved amount is calculated based on CGHS guidelines and rate lists. Reimbursement is issued directly to the beneficiary’s bank account, usually within a few weeks, depending on processing time.
  
  
• Common Reasons for Claim Rejection:
• Submission of incomplete or incorrect documents.
• Treatments or procedures not listed under CGHS-approved guidelines.
• Expenses exceeding CGHS-approved rates for procedures or medicines.
• Lack of proper referral or prior approval for specialist consultations and hospitalisation.
• Claims submitted after the prescribed deadline.
  
  
• Tracking Claims: Beneficiaries can track the status of their reimbursement claims online or by contacting the concerned CGHS dispensary to ensure timely processing.

Applicable Cities Under the Central Government Health Scheme

List of Cities Covered Under CGHS:

The Central Government Health Scheme is currently available in major cities where central government offices and establishments are present. This includes metros such as Delhi, Mumbai, Kolkata, Chennai, Bengaluru, Hyderabad, Pune, and Ahmedabad, as well as other significant cities like Lucknow, Jaipur, Bhopal, Chandigarh, and Patna. Each city has multiple CGHS wellness centres or dispensaries to provide easy access to beneficiaries.

Expansion of CGHS Network:

Over the years, the CGHS network has expanded beyond the initial metropolitan centres to cover smaller cities and towns with a substantial population of central government employees and pensioners. New dispensaries, wellness centres, and empanelled hospitals are regularly added to improve accessibility and reduce the travel burden for beneficiaries. The scheme also aims to integrate digital services and online appointment systems to make healthcare more convenient in expanding locations.

Availability of CGHS Services Across India:

While CGHS coverage is primarily focused on urban areas, beneficiaries living in cities outside CGHS zones can access treatment through empanelled hospitals and may claim reimbursement for eligible expenses. The scheme ensures that critical and specialist medical care is available even in locations without a full CGHS facility, usually through referral systems to the nearest empanelled hospitals. Telemedicine and online consultation options are also being introduced in certain areas to further extend healthcare reach.

Coordination with Other Healthcare Facilities:

In addition to dispensaries and empanelled hospitals, CGHS maintains coordination with government and private medical facilities in non-CGHS cities to ensure continuity of care for beneficiaries, especially for chronic or emergency treatments.

Importance of the Central Government Health Scheme

Importance Area	Details
CGHS as a Social Security Measure	CGHS provides a structured healthcare safety net for central government employees, pensioners, and their dependents, ensuring access to quality medical care when needed.
Reducing Healthcare Costs	The scheme significantly lowers out-of-pocket expenses by providing free or subsidised consultations, medicines, diagnostics, and hospitalisation.
Healthcare Security During Service and Retirement	CGHS ensures continuous medical coverage for employees during their service period and extends benefits to pensioners and eligible dependents after retirement.
Promotes Preventive Healthcare	By offering regular check-ups, diagnostics, and early disease detection, CGHS helps prevent severe illnesses and reduces long-term treatment costs.
Standardised and Transparent Care	CGHS rate lists and approved procedures ensure transparency, protect beneficiaries from overcharging, and maintain uniform quality of care across all facilities.

Why You Should Opt for ManipalCigna Health Insurance Along with the Central Government Health Scheme

Opting for ManipalCigna Health Insurance alongside the Central Government Health Scheme (CGHS) helps bridge coverage gaps and enhances overall healthcare security. While CGHS provides strong foundational coverage, an additional private health insurance plan ensures greater flexibility and financial protection.

• Provides access to a wider network of private hospitals beyond CGHS empanelled facilities.
• Covers medical expenses not admissible under CGHS, such as higher room rent and non-empanelled hospital treatments.
• Offers a higher sum insured of more than Rs 5,00,000, which many government schemes offer for costly or advanced medical procedures.
• Ensures faster and more flexible claim settlements without dependency on CGHS referrals or approvals.

FAQs

Who can be beneficiaries under the Central Government Health Scheme?

Central government employees, pensioners, and their eligible dependents.

Is treatment under the Central Government Health Scheme cashless?

Yes, cashless treatment is available at CGHS facilities and empanelled hospitals.

What medical systems are covered under CGHS?

Allopathy and AYUSH systems are covered.

What should I do if I face issues with CGHS services?

You can raise grievances through the CGHS administrative channels.

What is included in the CGHS card benefits?

OPD care, hospitalisation, diagnostics, medicines, and reimbursement facilities.